Excellent Recovery of Shoulder Movements After Decompression and Neurolysis of Long Thoracic Nerve in Teen Patients With Winging Scapula.

Introduction: In teens, athletes, in general, have been found to have shoulder pain and or winging scapula resulting from long thoracic or spinal accessory nerve injuries. Accident (fall) and stretch injuries due to overuse and poor sports techniques mainly cause these injuries that affect their upper extremity movements and functions. Here, we report a significant improvement in scapula winging and shoulder active range of motion in 16 teen patients after long thoracic nerve decompression and neurolysis. Patients and Methods: This was a retrospective study of 16 teen patients who had severe winging scapula and poor shoulder movements and function. Therefore, they underwent decompression and neurolysis of long thoracic nerve with us, between 2005 and 2016. The average patient age was 17 years (range, 14-19 years). These patients had been suffering from paralysis for an average of 15 months (range, 2-48 months). All patients underwent a preoperative electromyographic assessment in addition to clinical evaluation to confirm the long thoracic nerve injury. Results: Scapula winging was severe in 10 of 16 patients (63%), moderate in 2 patients (12%), and mild in 4 patients (25%) in our present study. Mean shoulder abduction (128°) and flexion (138°) were poor preoperatively. Shoulder abduction and flexion improved to 180° in 15 patients (94%) and good (120°) in 1 patient (6%) at least 2 months after surgery. In 11 patients (69%), the winged scapula was completely corrected postsurgically and it was less prominent in other 5 patients. Conclusion: Long thoracic nerve decompression and neurolysis significantly improved scapular winging in all 16 teen patients in our present study, producing "excellent" shoulder movements in 15 patients (94%) and "good" result in 1 patient (6%).

or, less commonly, the dorsal scapular nerve. C5-C7 brachial plexus preganglionic injuries are also associated with complete paralysis of the LTN. 1 Several athletic activities are known to cause injury to LTN. 2 Most of our teen patients in this study had sports-related injuries, because of overuse and practicing poor sports technique, 3 as well as accidents. Moreover, they are skeletally immature. 3 As the LTN passes along the thorax, it can be compressed by blood vessels and/or fibrotic tissue. 4 Although some investigators have recommended conservative treatment of this condition, 5 often timely surgical treatment 6 is vital to the recovery of scapular winging secondary to LTN palsy. 7 Recently, we have analyzed and compared the effectiveness of muscle and tendon operative procedures to decompression and neurolysis of LTN and demonstrated that LTN decompression is an easy and effective treatment to correct winging scapula. 8 Here, we report a significant improvement in scapula winging and active range of motion (AROM) of the shoulder in 16 teen patients after LTN decompression and neurolysis.

PATIENTS AND METHODS
Of 555 patients who visited our clinic with winging scapula since 2005, 16 teenage patients met the inclusion criteria of this study.

Inclusion criteria
1. Teen patients (aged between 13 and 19 years) who had winging scapula were clinically evaluated by the lead author (R.K.N.) and LTN injury was confirmed by electromyography (EMG). 2. Teen patients who had LTN decompression and neurolysis procedure at our clinic.

Exclusion criteria
1. Teen patients who had LTN injury and winging scapula and who were included in our previously published studies. 9-11 2. Teen patients who have no postoperative follow-up.
This was a retrospective study of 16 teen patients who had winging scapula and therefore underwent LTN decompression between 2005 and 2016, as described in our previous publications. 9,10 The average patient age was 17 years (range, 14-19 years). Patients had been suffering from paralysis for an average of 1.3 years (range, 2-48 months). All patients underwent a preoperative electromyographic assessment in addition to clinical evaluation to confirm the LTN injury. We adopted a 4-point numerical scale for determining the extent of scapula winging: 1, severe; 2, moderate; 3, mild; and 4, normal as shown in Figure 1. The angle of humeral elevation before and after surgical neurolysis of the LTN was captured on the video. Stills were taken from the video of the patients performing abduction, and the angle between a line parallel to the medial line and the humerus was measured (0 • being relaxed at the side and 180 • being fully abducted above the head). The paired Student t-test statistics was applied to compare the pre-and postoperative mean Mallet and supination scores using the Analyze it plugin (Leeds, UK) for Microsoft Excel 2003. A value of P < .05 was considered statistically significant. ePlasty VOLUME 19 This was a retrospective study of patient charts, which exempted it from the need for institutional review board approval in the United States. Patients were treated ethically in compliance with the Helsinki declaration. Documented informed consent was obtained for all patients.

DISCUSSION
We 8-10 and other investigators [15][16][17] have demonstrated that surgical release of LTN and spinal accessory nerve 18 as a simple and effective treatment that significantly improves winging scapula and shoulder AROM, [8][9][10] which relieves pain and provides complete motor recovery, 15 when performed within the first 12 months of the paralysis. 15 In addition, in our previously published meta-analysis report, 8 we compared and analyzed the outcomes of long thoracic or spinal accessory nerve decompression and neurolysis with muscle transfer procedures and found that nerve surgical procedures are effective techniques in correcting winging scapula in comparison with muscle and tendon transfer operations.
Vastamäki et al 19 recently reported how etiology influences long-term outcome of LTN damage. They found that LTN-related palsies caused by infection recover better and those caused by surgery in the body or anesthesia 19 recover most poorly. These palsies caused by acute trauma or acute or chronic overuse of upper extremities had the same recovery period as other patients. Etiology of LTN injury had less influence on long-term outcomes. We did not have any patient in this study who had LTN injury and winging scapula due to infection. Our patients' outcome data and recovery also substantiate the findings of Vastamäki et al. 19 Our data confirm that etiology did not influence significantly in our patient outcomes after surgical LTN decompression treatment.
Mechanism of LTN injury is generally mechanical in origin. Most of our patients in this study had sports-related injuries, and these are mechanical in nature. Glenohumeral instability, scapula winging, proximal humeral physis, and shoulder pain are important to recognize and address early, as these can cause more severe complications later in these growing teen and preteen athletes and other young patients.

CONCLUSION
Both LTN decompression and neurolysis significantly improved scapular winging in all 16 teen patients in our present study, producing "excellent" shoulder movements in 15 patients (94%) and "good" result in one patient (6%).